Citation Nr: 1120301 Decision Date: 05/25/11 Archive Date: 06/06/11 DOCKET NO. 09-23 627 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to service connection for a disability manifested by dizziness, to include as secondary to service-connected tinnitus. 2. Entitlement to service connection for essential thrombocythemia. 3. Entitlement to an initial evaluation in excess of 10 percent for loss of lung capacity. 4. Entitlement to an increased evaluation for thoracotomy scar, currently evaluated as 10 percent disabling. 5. Entitlement to a separate compensable evaluation for a muscle group injury, residual of thoracotomy (previously characterized and claimed as service connection for loss of mobility and/or restrictive movement due to shift of the lung in chest cavity drawing the diaphragm up and causing muscle spasms, secondary to status post thoracotomy). 6. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Calvin Hansen, Attorney at Law ATTORNEY FOR THE BOARD R. Poulson, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1967 to July 1971. This matter is before the Board of Veterans' Appeals (Board) from a rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. In May 2004, the Veteran sought to reopen a claim of service connection for lung cancer. He also filed secondary service connection claims for muscle strain under arm and in rib cage, and breathing problems. In October 2004, the RO denied service connection for (1) carcinoid tumor of the right lung with right upper lobectomy, and (2) residuals painful symptoms between ribs laterally at surgical site and anteriorly at the costochondral junction (costochondritis). In January 2006, the RO granted service connection for "carcinoid tumor right upper lobe, status post thoracotomy and surgical removal, no recurrence with residual pain symptoms between ribs laterally and surgical site and anteriorly at the costochondral junction; and scar," and awarded a 10 percent evaluation "for all residuals due to [] tumor removal using the regulation for scars." In September 2006, the RO granted an increased evaluation of 100 percent, effective February 25, 1994, and an effective date of February 1, 1996 for the 10 percent evaluation. In June 2008, the Veteran filed a claim for "loss of mobility and/or restrictive movement due to the shift of the lung in the chest cavity drawing the diaphragm up and causing muscle spasms." The RO construed this correspondence as a new service connection claim, which it denied in September 2008. The RO also denied service connection for Meniere's disease and essential thrombocythemia, granted service connection for loss of lung capacity and awarded a noncompensable evaluation, and denied an increased evaluation for the thoracotomy scar. In August 2009, the RO denied entitlement to TDIU. Although the RO separately adjudicated a service connection claim for loss of mobility and/or restrictive movement due to shift of the lung in chest cavity drawing the diaphragm up and causing muscle spasms, the Veteran does not appear to be seeking service connection for any disorder. Rather, he wants a compensable evaluation for the disability for which he has already been awarded service connection, namely, residuals of thoracotomy. Accordingly, the scar and muscle group issues have been re-characterized to more accurately reflect the procedural history, the medical evidence, and the Veteran's claims. The dizziness issue has also been recharacterized to more accurately reflect the medical evidence and the Veteran's claims. Additional evidence was received after the issuance of the supplemental statement of the case in February 2010, without a waiver of review by the RO. However, the newly submitted evidence confirms that the Veteran is receiving benefits from the Social Security Administration (SSA). Records from the SSA are already of record. Therefore, the Veteran is not prejudiced by the Board reviewing the claim. See 38 C.F.R. §§ 20.800, 20.1304 (2010) (noting that the Board must refer pertinent evidence to the agency of original jurisdiction) (emphasis added). The issues of entitlement to service connection for a disability manifested by dizziness, entitlement to a separate compensable evaluation for a muscle group injury, and entitlement to TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Department of Veterans Affairs Regional Office. FINDINGS OF FACT 1. Essential thrombocythemia was first demonstrated years after service and the probative, competent medical evidence of record does not link the disorder to active service. 2. The competent medical evidence shows that the Veteran's loss of lung capacity is not manifested by a forced expiratory volume in one second (FEV- 1) of 70 percent or less than predicted, a Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB)) of 65 percent or less than predicted, the need for daily inhalational or oral bronchodilator therapy or inhalational anti-inflammatory medication, incapacitating episodes of infection of two to four weeks total duration per year, or daily productive cough with sputum that is at times purulent or blood-tinged and that requires prolonged (lasting four to six weeks) antibiotic usage more than twice a year. 3. The Veteran's thoracotomy scar is well healed, but painful; there is no limitation of function, and it is not at least 12 square inches in area. CONCLUSIONS OF LAW 1. The criteria for service connection for essential thrombocythemia have not been met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. § 3.102, 3.159, 3.303 (2010). 2. The criteria for the assignment of an initial evaluation in excess of 10 percent for loss of lung capacity have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 4.1 - 4.7, 4.96, 4.97, Diagnostic Codes (DC) 6600, 6603, 6604, 6844 (2010). 3. The criteria for the assignment of an increased evaluation for thoracotomy scar have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 4.1 - 4.7, 4.118, Diagnostic Codes (DC) 7801, 7804 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Notice and Assistance Upon receipt of a complete or substantially complete application, VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a). The notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; (3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App.112 (2004). The notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). Once service connection is granted the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). No additional discussion of the duty to notify is required for the downstream issue of entitlement to an initial evaluation in excess of 10 percent for loss of lung capacity. With respect to the service connection and increased rating claims, the RO provided the Veteran pre-adjudication notice by letter dated in August 2007. The notification substantially complied with the specificity requirements of Dingess v. Nicholson, 19 Vet. App. 473 (2006) identifying the five elements of a service connection claim, and Quartuccio v. Principi, 16 Vet. App. 183 (2002), identifying the evidence necessary to substantiate a claim and the relative duties of VA and the claimant to obtain evidence. The notice also included the general criteria for substantiating an increased rating claim, but did not contain the applicable diagnostic codes for the increased rating. Notice described in 38 U.S.C. § 5103(a), however, need not be veteran-specific and generic notice is all that is required. See Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1281 (Fed.Cir. 2009). In any event, the Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notices. See Shinseki v. Sanders, 129 U.S. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination); see also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). VA has obtained all available service treatment records (STRs) and VA treatment records, assisted the Veteran in obtaining evidence, and obtained a medical opinion as to the severity of his thoracotomy scar and loss of lung capacity. VA respiratory examinations with pulmonary function testing (PFT) were conducted in August 2008 and June 2009, with addendums dated September 2008, March 2009, and June 2009. A VA scar examination was conducted in August 2009. The Veteran has not argued, and the record does not reflect, that these examinations were inadequate for rating purposes. See 38 C.F.R. § 3.159(c) (4); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). The examiner provided an opinion as to the severity of these disabilities based on examination of the Veteran, his reported history, and the entire claim file. The Veteran did not desire a personal hearing. A VA examination was not provided with respect to the essential thrombocythemia claim. In a claim for disability compensation, VA will provide a medical examination or obtain a medical opinion based upon a review of the evidence of record if VA determines it is necessary to decide the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). A medical examination is necessary when the record (1) contains competent evidence that the claimant has a current disability or persistent or recurrent symptoms of the disability; (2) contains evidence, which indicates that the disability or symptoms may be associated with the claimant's active duty; and (3) does not contain sufficient medical evidence for VA to make a decision. 38 U.S.C.A. § 5103A(d); McClendon v. Nicholson, 20 Vet. App. 79, 83 (2006). While the Veteran has a current diagnosis of essential thrombocythemia, as discussed below, there is no evidence that the condition was incurred in or aggravated by service. Thus, no VA examination is necessary in order to decide this claim. All known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claim file; and the Veteran has not contended otherwise. VA has substantially complied with the notice and assistance requirements and the appellant is not prejudiced by a decision on the claims at this time. II. Service Connection Service connection will be granted if it is shown that the veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). To establish service connection, there must be a medical diagnosis of a current disability; medical or, in certain cases, lay evidence of in-service occurrence or aggravation of a disease or injury; and competent evidence of a nexus between an in-service injury or disease and the current disability. Hickson v. West, 12 Vet. App. 247, 252 (1999). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran contends that he has essential thrombocythemia related to service. STRs are devoid of any complaint, finding, or treatment of thrombocythemia or any other blood disorder. The Veteran was not diagnosed with essential thrombocythemia until December 2007 after a bone marrow biopsy. VA treatment records establish that the Veteran had a normal platelet count in 1998, but has had an elevated platelet count since 2001. There is no medical evidence linking the Veteran's current essential thrombocythemia to active service. The earliest evidence of treatment for essential thrombocythemia is December 2007. This is 36 years after separation from service, and this period without treatment is evidence that there has not been a continuity of symptomatology, and it weighs heavily against the claim on a direct basis. See generally Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (aggravation in service may be rebutted by the absence of medical treatment for the claimed condition for many years after service). Nor has the Veteran reported a continuity of elevated platelets since service. Indeed, the medical records establish that the Veteran had a normal platelet level in 1998, with no evidence of elevated platelets until 2001. None of these records mention the Veteran's service, and they do not relate his thrombocythemia to service or to any event therein. The preponderance of the evidence is against the claim; there is no doubt to be resolved; service connection for essential thrombocythemia is not warranted. III. Increased Rating Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Where there is a reasonable doubt as to the degree of disability, such doubt shall be resolved in favor of the claimant, and where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. §§ 3.102, 4.3, 4.7. In addition, the potential application of the various other provisions of 38 C.F.R., Parts 3 and 4 will be considered, whether or not they were raised by a veteran, as well as the entire history of a veteran's disorder in reaching its decision, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In a claim for a greater original rating after an initial award of service connection, all of the evidence submitted in support of a veteran's claim is to be considered. Fenderson v. West, 12 Vet. App. 119 (1999); 38 C.F.R. § 4.2. Where entitlement to compensation already has been established and an increased disability rating is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Different percentage ratings for different periods of time can be applied based on the medical evidence of record. Hart v. Mansfield, 21 Vet. App. 505 (2007). Once the evidence is assembled, the Secretary is responsible for determining whether the preponderance of the evidence is against the claim. Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990). If so, the claim is denied; if the evidence is in support of the claim or is in equal balance, the claim is allowed. Id. Loss of Lung Capacity The RO granted service connection for loss of lung capacity in September 2008 and assigned a noncompensable evaluation, effective June 16, 2008. In June 2009, the RO granted an increased evaluation of 10 percent, effective June 16, 2008. This disability has been rated under 38 C.F.R. § 4.97, Diagnostic Code 6844. Diagnostic Code 6844 provides for evaluations pursuant to the General Rating Formula for Restrictive Lung Disease. The General Rating Formula assigns a 10 percent disability rating when there is FEV-1 (Forced Expiratory Volume) of 71- to 80- percent predicted, or; FEV-1/FVC (Forced Vital Capacity) of 71 to 80 percent, or; DLCO (Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method) 66-to 80-percent predicted. FEV-1 of 56- to 70-percent predicted, or; FEV-1/FVC of 56 to 70 percent, or; DLCO (SB) 56- to 65- percent predicted, is rated 30 percent disabling. A 60 percent rating is warranted if FEV-1 is 40 to 55 percent of predicted value, FEV-1/FVC is 40 to 55 percent, DLCO (SB) is 40 to 55 percent predicted, or if maximum oxygen consumption is 15 to 20 ml/kg/min (with cardiorespiratory limit). FEV-1 less than 40 percent of predicted value, or; FEV-1/FVC less than 40 percent, or; DLCO (SB) less than 40-percent predicted, or; maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation), or; cor pulmonale (right heart failure), or; right ventricular hypertrophy, or; pulmonary hypertension (shown by Echo or cardiac catheterization), or; episode(s) of acute respiratory failure, or; requires outpatient oxygen therapy, is rated 100 percent disabling. 38 C.F.R. § 4.97, Diagnostic Code 6844. When evaluating a respiratory disorder based on PFTs, post-bronchodilator results must be used in applying the evaluation criteria in the rating schedule unless the post-bronchodilator results were poorer than the pre-bronchodilator results. In those cases, the pre-bronchodilator values must be used for rating purposes. 38 C.F.R. § 4.96(d)(5). When there is a disparity between the results of different PFT FEV-1 (Forced Expiratory Volume in 1 Second) and FVC (Forced Vital Capacity), so that the level of evaluation would be different depending on which test result is used, the test result is used that the examiner states most accurately reflects the level of disability. 38 C.F.R. § 4.96(d)(6). An October 2006 VA treatment record shows that the Veteran had been prescribed an Albuterol inhaler two puffs four times per day as needed for cough or shortness of breath. In December 2006, the Veteran reported that he was coughing more, and that it was productive at times. The clinician noted an expiratory wheeze in the right chest that "nearly clear[ed]" with coughing. The diagnosis was COPD with exacerbation; a 6-day Prednisone dose pack was prescribed. Albuterol is listed as an active medication. In October 2007, the Veteran denied any dyspnea on exertion, but reported a productive cough in the afternoon, yellow to clear. Treatment records after November 2007 do not list Albuterol is as an active medication. In March 2008, the Veteran reported that the yellow productive cough was improving. The clinician diagnosed an upper respiratory infection with sinusitis and prescribed bactrim. Later than month, the Veteran was switched to another antibiotic (Doxycycline). An August 2008 VA examination report shows that the Veteran complained of shortness of breath with moderate exertion and a productive cough. He was employed full-time by the U.S. Postal Service. PFT results were: pre-bronchodilator FEV-1 of 71.1 percent of predicted and post-bronchodilator FEV-1/FVC of 62 percent, and postbronchodilator FEV-1 of 71.3 percent predicted; FEV-1/FVC of 61 percent predicted; and a DLCO of 67.8 percent predicted. A March 2009 VA treatment record shows that the Veteran reported shortness of breath "at times" and stated that he "might get a little dyspnea on exertion with walking uphill fast. In April and July 2009, he denied any cough or shortness of breath. A June 2009 VA examination report shows that the Veteran complained of difficulty breathing. He also reported a daily productive cough; the sputum was occasionally clear, never purulent, and he had had one episode of blood streak within the previous few months. He also complained of dyspnea at rest and with exertion. PFT results were: prebronchodilator FEV-1 of 73 percent predicted; FEV-1/FVC of 58 percent predicted; and a DLCO of 81 percent predicted. The clinician wrote "suspected less than optimal PT effort." In a June 2009 addendum, the same examiner noted that the Veteran's FEV-1 most accurately reflected the Veteran's pulmonary condition. Prebronchodilator PFT testing in August 2008 showed an FEV-1 of 71 percent predicted and a DLCO of 68 percent predicted, while June 2009 prebronchodilator PFT testing showed an FEV-1 of 73 percent predicted and a DLCO of 81 percent predicted. These findings fall short of the criteria for a 30 percent evaluation under DC 6684. The Veteran did have an August 2008 FEV1/FVC ratio of 62 percent predicted and a July FEV1/FVC ratio of 58 percent predicted, which technically meet the criteria for a 30 percent evaluation. However, the VA examiner noted the disparity of the FEV-1/FVC readings with the remaining PFT results and determined that the Veteran's FEV-1 result best correlated with the severity of his case. Furthermore, the June 2009 examiner had concluded that the Veteran's effort was "less than optimal." Accordingly, the Board accepts the August 2008 FEV-1 result as the best indicator of disability level. 38 C.F.R. § 4.96(d)(6); see also 71 Fed. Reg. 52457-01 (Sept. 6, 2006). For these reasons, an evaluation in excess of 10 percent for service-connected loss of lung capacity is not warranted under DC 6684. The Board has considered whether the Veteran could receive a higher compensable evaluation based on other diagnostic codes. A 30 percent evaluation under DCs 6600, 6603, and 6604 involves the same criteria as a 30 percent evaluation under DC 6844. Under DC 6601, a 30 percent evaluation is warranted for incapacitating episodes of infection of two to four weeks total duration per year, or daily productive cough with sputum that is at times purulent or blood-tinged and that requires prolonged (lasting four to six weeks) antibiotic usage more than twice a year. The Veteran was treated for a daily productive cough between October 2007 and March 2008, and in June 2009 he reported one occasion of blood-tinged sputum. However, the evidence shows only one antibiotic prescription, in March 2008. Under DC 6602, a 30 percent evaluation is warranted when daily inhalational or oral bronchodilator therapy or inhalational anti-inflammatory medication is required. The evidence shows that the Veteran used an Albuterol inhaler two puffs four times per day as needed, rather than daily from October to December 2006. Accordingly, a 30 percent evaluation is not warranted. Thoracotomy Scar In January 2006, the RO granted service connection for thoracotomy scar and assigned a 10 percent evaluation. This disability has been rated under 38 C.F.R. § 4.97, Diagnostic Code 6844-7804. A scar not involving the head, face, or neck can be rated under Diagnostic Codes 7801, 7802, 7804, and/or 7805. 38 C.F.R. § 4.118. Under DC 7801, scars other than of the head, face or neck that are deep or that cause limited motion warrant a 20 percent evaluation when they cover an area or areas exceeding 12 square inches. 38 C.F.R. § 4.118. Ten percent is the maximum possible evaluation under DC 7802. Under DC 7804, a 20 percent evaluation is warranted for three of four scars that are unstable or painful. A September 2004 VA respiratory examination report establishes that the Veteran had a surgical scar on the right lateral thorax that measured 19 cm in length by approximately .25 cm in width. It was soft and flat, with significant loss of underlying tissue. It was not considered disfiguring. There was no indication of skin breakdown or ulcerations. It was tender to very firm palpation with introduction of the fingertips between the ribs to a deep level. It was not tender to light touch. The August 2009 VA examiner noted that the Veteran had "no complaints" with respect to the scar. The June 2009 VA examiner noted that there is no deformity of the chest wall. There is no medical evidence of record indicating that the Veteran's single scar is deep and nonlinear, is 12 square inches or more, or is unstable. Therefore, the Veteran's thoracotomy scar does not warrant an increased evaluation under DCs 7801-7804. DC 7805 indicates that scars can be rated on limitation of function of the affected part. 38 C.F.R. § 4.118, DC 7805. The evidence does not show any limitation of motion caused by the chest scar. See 38 C.F.R. § 4.71a, Diagnostic Code 5242 (2010). The Veteran has complained of loss of mobility and/or restrictive movement associated with a residual muscle injury; this issue is addressed in the remand order. The scar regulations were amended effective October 23, 2008 to provide for evaluation of burn scars under DCs 7800-7802. 38 C.F.R. § 4.118, effective October 23, 2008. DC 7803 was eliminated. Id. The provisions of DCs 7804 and 7805 remained essentially unchanged. The regulatory changes only apply to applications received by VA on or after October 23, 2008, or if the Veteran requests review under the clarified criteria. See 73 Fed. Reg. 54,708 (Sept. 23, 2008). As neither situation applies in this case, the Board will not consider the 2008 changes. In any event, the Veteran does not have a burn scar, and has never been evaluated under DC 7803. Therefore, the change in the regulations is not applicable. Consideration has also been given regarding whether the schedular evaluations are inadequate, requiring that the RO refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of an extra-schedular evaluation where a service-connected disability presents an exceptional or unusual disability picture with marked interference with employment or frequent periods of hospitalization that render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating, otherwise, the schedular evaluation is adequate, and referral is not required. Id. at 116. The schedular evaluations in this case are adequate. Ratings in excess of those assigned are provided for certain manifestations of the service-connected disorders but the medical evidence reflects that those manifestations are not present in this case. Additionally, the diagnostic criteria adequately describe the severity and symptomatology of the Veteran's disabilities. The Veteran has not required hospitalization due to these service-connected disabilities, and there is no evidence of a marked interference with his employment solely due to loss of lung capacity or the thoracotomy scar. Indeed, the Veteran informed the August 2009 VA examiner that he had retired from the U.S. Postal Service in December 2008 because of joint and back problems. Therefore, the Veteran's disability picture is contemplated by the rating schedule and no extraschedular referral is required. ORDER Service connection for essential thrombocythemia is denied. An initial evaluation in excess of 10 percent for loss of lung capacity is denied. An increased evaluation for thoracotomy scar, currently rated at 10 percent, is denied. REMAND Dizziness The Veteran complained of dizzy spells, as well as headaches, numerous times during service. Post-service records do not provide a diagnosis of a disability manifested by dizziness, to include Meniere's disease. However, during a December 2002 VA examination conducted in connection with his tinnitus and hearing loss claims, the Veteran reported hearing loss; occasional vertigo, particularly with rapid movement; and constant tinnitus. The examiner did not provide an opinion regarding the etiology of his complaints. A December 2006 VA treatment record shows that the Veteran reported ringing in the ears and dizzy spells "at times . . . most always while walking or other movement." The Veteran denied any dizziness in April and July 2009. However, a September 2009 VA treatment record shows that the Veteran reported daily dizziness of 4-5 months' duration that was stimulated by rapid change in position. The clinician wrote "asks about association with ear condition." Accordingly, the issue of service connection on a secondary basis has been raised and should be properly adjudicated. See Robinson v. Nicholson, 21 Vet. App. 553 (2008). A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). This includes any increase in severity of a nonservice-connected disease that is proximately due to or the result of a service-connected disability as set forth in 38 C.F.R. § 3.310(b). See also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). 38 C.F.R. § 3.310 (pertaining to secondary service connection) was amended effective October 10, 2006. Review of the record indicates that proper notice was not provided. This must be done. Accordingly, the Veteran should be afforded a VA examination in order to determine the nature and etiology of any disability manifested by dizziness, to include Meniere's disease. See 38 C.F.R. § 3.159 (c)(4); 38 U.S.C.A. § 5103A(d) (West 2002); McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006). Muscle Group Injury In January 2006, the RO granted service connection for carcinoid tumor right upper lobe, status post thoracotomy and surgical removal, no recurrence with residual pain symptoms between ribs laterally and surgical site and anteriorly at the costochondral junction; and scar. A 10 percent evaluation was assigned under DCs 6684-7804. An October 2006 VA treatment record shows that the Veteran complained of muscle pains after exercise-workouts. In June 2008, the Veteran complained of loss of mobility and/or restrictive movement due to the shift of the lung in the chest cavity drawing the diaphragm up and causing muscle spasms. An August 2008 VA examination report shows that the Veteran complained of right rib pains, as well as pain and cramping about the right diaphragm, especially when working on machines at work. X-rays showed tenting of the right hemidiaphragm silhouette. The examiner noted that "thoracotomy procedures are certainly not innocent . . . they go through multiple layers of tissue and enter the chest cavity." He opined that the minimal tenting and discomfort in the right hemidiaphragm area were at least as likely as not secondary to the lung surgery. In a September 2008 addendum, the VA examiner noted that the Veteran did not appear to have any loss of mobility or restrictive movement, but did appear to have pain. He wrote "[the Veteran] is likely splinting the right hemithorax/right chest because of the previous operative procedure and discomfort associated with that thoracotomy, which may cause him to have more pain when performing certain movements, and avoiding certain movements associated with the right chest." In January 2009, the Veteran complained of back pain. The clinician wrote "he has been leaning a lot to the side because of his surgery and this may be muscular pain." X-rays showed postoperative changes right hilum. A June 2009 VA examination report shows that the Veteran reported occasional right costal margin chest pain at rest and on exertion. Diaphragm excursion was slightly limited. An August 2009 VA examination report establishes that the Veteran complained of daily chest wall pain, mostly under the right ribs. The diagnosis was residual ongoing chest wall pain. Accordingly, remand is required to clearly identify any muscle groups affected by the service-connected thoracotomy and to describe the severity of the effect on each muscle group. TDIU The appeal for assignment of TDIU is inextricably intertwined with the issue of entitlement to service connection for a disability manifested by dizziness and a separate compensable evaluation for a muscle group injury. Service connection is currently in effect for generalized anxiety disorder (rated 30 percent); mechanical low back strain (rated 20 percent); thoracotomy scar (rated 10 percent); anterolateral medial meniscal tear, left knee (rated 10 percent); chronic dermatitis (rated 10 percent); tinnitus (rated 10 percent); musculoligamentous strain, right knee (rated 10 percent); loss of lung capacity (rated 10 percent); and scar, right lower leg, residuals of excision of tissue (rated noncompensable). The combined rating of all service-connected disabilities is 70 percent. The record reflects that the Veteran receives disability benefits from the Social Security Administration (SSA). The Veteran was found totally disabled by SSA as of November 2008 due to his service-connected back disability and anxiety disorder. The Board is not bound by the findings of disability and/or unemployability made by other agencies, including SSA. See Collier v. Derwinski, 1 Vet. App. 413, 417 (1991) (indicating the SSA's favorable determination, while probative evidence to be considered in the claim with VA, is not dispositive or altogether binding on VA since the agencies have different disability determination requirements). The evidence of record is equivocal as to whether the Veteran's service-connected disabilities alone render him unemployable. Specifically, an August 2009 VA examination report considered all of the Veteran's service-connected disabilities except loss of lung capacity. The Veteran informed the examiner that he had retired from the U.S. Postal Service in December 2008 because of joint and back problems. With respect to the Veteran's generalized anxiety disorder, the examiner found that there was no total occupational impairment; however, he opined that there were "intermittent periods of inability to perform occupational tasks." With respect to the Veteran's knees, he found that there was decreased mobility, problems with lifting and carrying, and decreased strength. The examiner did not offer an opinion as to the Veteran's employability with respect to his other service-connected disabilities, noting only that he was retired. Accordingly, additional VA examination of the Veteran is warranted. When the medical evidence is inadequate, VA must supplement the record by seeking an advisory opinion or ordering another medical examination. Colvin v. Derwinski, 1 Vet. App. 171 (1991) and Hatlestad v. Derwinski, 3 Vet. App. 213 (1992). Finally, a VA Form 21- 8940, Veteran's Application for Increased Compensation Based on Unemployability, is not of record. Accordingly, the case is REMANDED for the following action: 1. Notify the Veteran and his representative of 38 C.F.R. § 3.310 and an amendment to that regulation, effective October 10, 2006, for the purpose of implementing the holding in Allen v. Brown, 7 Vet. App. 439 (1995) for secondary service connection on the basis of the aggravation of a nonservice-connected disorder by service-connected disability. See 71 Fed. Reg. 52744 (2006). 2. Send the Veteran VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, for him to complete, with instructions to return the form to the RO. 3. Schedule the Veteran for a VA ENT examination to determine the nature, extent, and etiology of any current disequilibrium/dizziness. The claim folder, and a copy of this remand, must be made available to and be reviewed by the examiner in conjunction with the examination and that review should be noted in the examination report. The examiner should provide opinions on the following: (a) Whether the Veteran suffers from Meniere's disease. (b) Whether it is at least as likely as not that any diagnosed dizziness, to include Meniere's disease, had its onset during active service. The examiner must specifically address the numerous service treatment records and post treatment records that reference the Veteran's complaints of dizziness. (c) Whether it is at least as likely as not that the Veteran's service-connected tinnitus caused or aggravated any current disability manifested by dizziness, to include Meniere's disease. The examiner must specifically address the December 2002 VA examination report and the September 2009 VA treatment record. All opinions should be accompanied by a clear rationale consistent with the evidence of record. If the examiner feels that the requested opinions cannot be rendered without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). 4. Schedule the Veteran for a VA examination with an appropriate medical professional to determine whether the Veteran has current muscle residuals from the 1994 thoracotomy. The claim folder, and a copy of this remand, must be made available to and be reviewed by the examiner in conjunction with the examination and that review should be noted in the examination report. The examiner should determine whether there is any muscle injury, and comment as to whether the disability associated with any affected muscle(s) would be considered moderate, moderately severe, or severe. (Each muscle group affected should be specified.) The examiner should also comment concerning the presence or absence of the cardinal signs and symptoms of muscle disability, including loss of power, weakness, lowered threshold of fatigue, pain, impairment of coordination, and uncertainty of movement. All opinions should be accompanied by a clear rationale consistent with the evidence of record. If the examiner feels that the requested opinion cannot be rendered without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). 5. Then, schedule an appropriate VA examination to determine employability. The report of examination should include a detailed account of all manifestations of all service-connected disabilities found to be present. All necessary tests should be conducted. The examiner should review the evidence of record and provide an opinion as to whether the Veteran is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities alone. The claim folder and a copy of this remand must be made available and reviewed by the examiner in conjunction with the examination. The examining physician should provide a complete rationale for all conclusions reached. 6. Thereafter, any additional development deemed appropriate should be accomplished. The RO should then re-adjudicate the claims. If any of the claims remain denied, the RO should issue a supplemental statement of the case (SSOC) and allow an appropriate period of time for response. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2010). ______________________________________________ RONALD W. SCHOLZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs